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Based on record reviews and interviews, it was determined that the Condition of Participation (CoP) for Patient Rights was not met. The facility failed to ensure physician orders were obtained and documented for 6 of 6 sampled patients who had restraints applied, and the facility failed to ensure that restrained patients were monitored and assessed consistent with facility policy and regulatory requirements for 5 of 6 sampled patients who had restraints applied.

Findings include:

This facility has failed to comply with the CoP for Patient Rights as evidenced by deficiencies identified as follows.

1. Standard: §482.12(c) also known as A168 - Based on record review and interview, the facility failed to ensure physician orders for restraint application were obtained and documented for 6 of 6 sampled patients (Patients A, B, C, D, E, and F). See A168 for details.

2. Standard: §482.13(e) (10) also known as A175 - Based on record review and interview, the facility failed to ensure that the patients who had restraints applied were assessed/monitored consistent with facility policy and regulatory requirements for 5 of 6 sampled patients (Patients A, B, C, E, and F). See A175 for details.

Based on record review and interview, it was determined that the facility failed to obtain a physician order for restraints for 6 of 6 patients sampled (Patients A, B, C, D, E, and F).

During a review of facility policies and patient restraint documentation, completed on August 30, 2016 the following was noted.

Findings include:

The hospital standards of practice reviewed included: York Hospital policy titled "Use of Restraints and Seclusion for Violent/Self-Destructive and Non-Violent/Non-Self-Destructive Behaviors" (TX).113 under "Initiating the Order for a Non-Violent/Non-Self-Destructive Restraint" states, in part, "An order for restraint must be obtained from a physician who is responsible for the care of the patient prior to the application of restraint." This policy further states, "Document the time the restraint was applied in the medical record" and "The original order for R/S (Restraint/Seclusion) must not exceed: 24 hours for adults."

York Hospital policy titled "Verbal or Telephone Orders" Policy N0. (IM).108 states, in part, "When taking a telephone order, the receiver must denote TO-V (telephone order-verified) to signify that the order has been read back to the prescriber, followed by the physician's name/name of person taking order/date and time", and, "When taking a Verbal order, the receiver must denote VO-V (Verbal order-verified) to signify that the order has been read back to the prescriber, followed by the physician's name/name of person taking order/date and time. This policy further requires that Verbal or Telephone orders must be dated, timed and authenticated within 48 hours by the ordering practitioner or by another practitioner who is responsible for the care of the patient.

1. A review of Patient Record A found the following:

a. Restraint order for "12/21" (no year indicated) with "V.O.V. (physician)" handwritten in "Physician Signature" and fails to contain date, time or name of person taking the order. The order fails to contain the authenticating documentation by the ordering physician.

b. Restraint order for "12/22/2015" contains a physician signature time that is illegible.

2. A review of Patient Record B found the following:

a. The patient medical record contains nursing documentation of patient restraints for January 7, 2016 at 10:15 AM through January 11, 2016 at 6:00 AM with no corresponding physician order for restraints.

b. Restraint order for 1/11/16 fails to contain documentation of: alternative interventions to restraints, patient education, and date and time of physician signature.

c. Restraint order for 1/12/16 failed to contain documentation of: reasons for restraint, alternative interventions to restraints, type of restraint, and patient education.

d. Restraint Order for 1/17/16 has "V.O.V. (physician) 1/17/ 1000" handwritten in the physician signature line and failed to contains date, time, or name of person taking the order. This order contain an electronic stamp which read "Authenticated by (Physician) on 02/17/2016 03:00:28 PM."

e. Restraint order for 1/18/16 documents restraints applied at "1000 hrs" and "New order required at 1000 1/19(2016)." Physician signature has a documented time of "0800."

f. Restraint order for 1/19/16 documents restraints applied at "1000 hrs" and "New order required at 1000 1/20(2016)." Physician signature has a documented time of "0730."

g. Restraint order for 1/20/16 fails to contain documentation of alternative interventions to restraints, and time of the physician's signature.

h. The patient medical record contains nursing documentation of patient restraints for January 21, 2016 with no corresponding physician order for restraints.

i. Restraint order for 1/22/16 fails to contain documentation of alternative interventions to restraints, patient education. and time of the physician's signature.

j. Restraint order for 1/23/16 fails to contain documentation of alternative interventions to restraints, and patient education. In the space for physician signature is an electronic stamp stating "Authenticated by (Physician) on 02/08/2016 12:13:32" and fails to contain documentation of verbal or telephone order.

k. Restraint order for 1/24/16 in the space for physician signature is an electronic stamp stating "Authenticated by (physician) on 02/08/2016 12:12:14" and fails to contain documentation of verbal or telephone order.

l. Restraint order for 1/25/16 in the space for physician signature is an electronic stamp stating "Authenticated by (physician) on 02/08/2016 12:16:24" and fails to contain documentation of verbal or telephone order.

3. A review of Patient Record C found the following:

a. Restraint order for 03/21/16 fails to contain physician's signature, date and time.

b. Restraint order for 03/22/16 fails to contain reason for restraint, type of restraint, and restraint duration. The order fails to contain physician's signature, date and time.

4. Patient Record D contains nursing "MedSurg Restraint" documentation for 04/20/2016 from 08:23 AM to 2:00 PM. The patient record fails to contain documentation of a physician's order for restraint for this date and time.

5. A review of Patient Record E found the following:

a. Restraint order for 01/25/2016 fails to contain documentation of alternative interventions to restraints. In the space for physician signature is an electronic stamp stating "Authenticated by (physician) on 02/08/2016 12:18:06" and fails to contain documentation of verbal or telephone order.

b. Restraint order for 02/26/2106 fails to contain documentation of reason for restraint, Alternative interventions to restraints, type of restraint, and patient education. In the space for physician signature is an electronic stamp stating "Authenticated by (physician) on 02/08/2016 12:13:41" and fails to contain documentation of verbal or telephone order.

6. A review of Patient Record F found the following:

a. Restraint order for 5/17/2016 fails to contain documentation of alternative interventions to restraints.

b. A second restraint order for 5/17/2016, by another provider, fails to contain a time of the physician signature.

c. Restraint order for 5/19/2016 fails to contain a time of the physician signature.

d. Medical record contains nursing restraint documentation for 05/20/2016 at 7:37 PM, to 5/22/2016 at 9:47 AM for which there is no documentation of a physician's order for restraint.

e. Restraint order for 5/22/2016 fails to contain documentation of the physician's signature, date and time.

Based on record review and interview, it was determined that the facility failed to provide evidence of assessment/monitoring of the restrained patient consistent with regulatory requirements and facility policy for 5 of 6 patients (Patient A, B, C, E, and F).

Findings include:

York Hospital policy titled "Use of Restraints and Seclusion for Violent/Self-Destructive and Non-Violent/Non-Self-Destructive Behaviors" Policy No. (TX).113 states under "Process for assessment and documentation during Restraint for Non-Violent/Non-Self-Destructive Behavior ... After the patient is restrained, the assigned nurse will ...Monitor and document on the Restraint Tab in Paragon at least every 2 hours while the patient is restrained ..."

1. Patient Record A contained a physician order for restraints and documented that restraints were applied on 12/21/16 at 1200 PM. The record fails to contain evidence or documentation of the required 2 hour restraint assessments between 12/21/2016 at 12:00 PM and 12/21/16 at 8:00 PM (a duration of 8hr 0min).

2. Patient Record B fails to contain evidence or documentation of the required 2 hour restraint assessments for the following periods of restraint:
a. 1/07/16- 2:00 PM to 5:53 PM (3hr 53 min) and 7:34 PM to 10:00 PM (2hr 26min).
b. 1/06/16- 6:23 AM to 7:17 PM (12hr 54min) and 7:17 PM to 10:07 PM (3hr 0min).
c. 1/09/16- 6:10 AM to 8:00 PM (13hr 50min).
d. 1/10/16- 6:00 AM to 8:00 PM (14hr 0min).
e. 1/11/16- 8:10 AM to 7:25 PM (11hr 15min).
f. 1/12/16- 2:04 AM to 6:03 AM (3hr 59min).
g. 1/17/16- 4:00 PM to 8:00 PM (4hr 0min).
h. 1/18/16- 6:00 AM to 10:00 AM (4hr 0min) and 5:00 PM to 8:00 PM (3hr 0min).
i. 1/19/16- 12:00 AM to 7:45 AM (7hr 45min) and 2:36 PM to 6:00 PM (3hr 24min).
j. 1/19/16- 8:00 PM to 1/20/16- 12:30 PM (16hr 30min).
k. 1/21/16- 12:41 AM to 4:31 AM (3hr 50min) and 12:00 PM to 4:00PM (4hr 0min).
l. 1/21/16 7:33 PM to 1/22/16- 12:00 AM (4hr 27min).
m. 1/22/16- 2:19 AM to 7:11 AM (4hr 52min) and 7:11 AM to 12:46 PM (5hr 35min).
n. 1/22/16- 1246 PM to 4:00 PM (3hr 14min) and 4:00 PM to 10:00 PM (6hr 0min).
o. 1/23/16- 12:00 AM to 6:00 AM (6hr 0min) and 6:00 AM to 2:26 PM (7hr 34min).
p. 1/23/16- 10:00 PM to 1/24/16- 8:00 PM (22hr 0min).
q. 1/24/16-8:00 PM to 1/25/16- 8:31 AM (12hr 31min).

3. Patient Record C fails to contain evidence or documentation of the required 2 hour restraint assessments for the following periods of restraint:
a. 3/18/16- 4:00 AM to 3:53 PM (11hr 53 min) and 3:53 PM to 7:47 PM (4hr 14min).
b. 3/18/16-10:00 PM to 3/19/16- 2:00 AM (4hr 0min).
c. 3/19/16- 7:12 AM to 10:00 AM (2hr 48min) and 10:00 AM to 8:41 PM (10hr 41min).
d. 3/19/16- 10:23 PM to 3/20/16- 1:33 AM (3hr 10min).
e. 3/21/16- 8:04 AM to 5:00 PM (8hr 56min).
f. 3/21/16-5:00 PM to 3/22/16 3:30 PM (22hr 30min).
g. 3/22/16- 3:30 PM to 7:00 PM (3hr 30min).

4. Patient Record E fails to contain evidence or documentation of the required 2 hour restraint assessments for the following periods of restraint:
a. 1/25/16- 2:30 PM to 7:00 PM (4hr 30min).
b. 1/25/16- 7:00 PM to 1/26/16- 8:00 AM (13hr 0min).

5. Patient Record F fails to contain evidence or documentation of the required 2 hour restraint assessments for the following periods of restraint:
a. 5/17/16- 8:44 PM to 5/18/16- 12:09 AM (3hr 25min).
b. 5/18/16- 2:28 AM to 6:00 AM (3hr 32min) and 10:00 AM to 1:15 PM (3hr 15min).
c. 5/18/16- 1:15 PM to 4:00 PM (2hr 45min).
d. 5/18/16- 7:03 PM to 5/19/16 7:15 AM (12hr 12min).
e. 5/19/16- 7:15 AM to 2:50 PM (7hr 35min).
f. 5/22/16-3:00 AM to 7:48 AM (5hr 48min).
g. 5/22/16- 9:47 AM to 2:00PM (4hr 13min).
h. 5/22/16- 9:00 PM to 5/23/16- 8:00 PM (23hr 0min).
i. 5/23/16-8:00 PM to 5/24/16- 7:31 AM (11hr 31min).
j. 5/24/16-7:31 AM to 10:00 AM (2hr 29min).

Based on record review and interview, the facility failed to identify deficient practice and opportunity for improvement in the area of patient rights related to physician orders, and patient assessment and monitoring during the period in which restraints were in use.

Findings include:

The hospital standards of practice reviewed included: York Hospital policy titled "Use of Restraints and Seclusion for Violent/Self-Destructive and Non-Violent/Non-Self-Destructive Behaviors" (TX).113 under "Initiating the Order for a Non-Violent/Non-Self-Destructive Restraint" states, in part, "An order for restraint must be obtained from a physician who is responsible for the care of the patient prior to the application of restraint." This policy further states, "Document the time the restraint was applied in the medical record" and "The original order for R/S (Restraint/Seclusion) must not exceed: 24 hours for adults." Additionally, the policy states under "Process for assessment and documentation during Restraint for Non-Violent/Non-Self-Destructive Behavior ... After the patient is restrained, the assigned nurse will ...Monitor and document on the Restraint Tab in Paragon at least every 2 hours while the patient is restrained ..."

York Hospital policy titled "Verbal or Telephone Orders" Policy N0. (IM).108 states, in part, "When taking a telephone order, the receiver must denote TO-V (telephone order-verified) to signify that the order has been read back to the prescriber, followed by the physician's name/name of person taking order/date and time", and, "When taking a Verbal order, the receiver must denote VO-V (Verbal order-verified) to signify that the order has been read back to the prescriber, followed by the physician's name/name of person taking order/date and time. This policy further requires that Verbal or Telephone orders must be dated, timed and authenticated within 48 hours by the ordering practitioner or by another practitioner who is responsible for the care of the patient.

1. Standard: §482.12(c) also known as A168 - Based on record review and interview, the facility failed to ensure physician orders for restraint application were obtained and documented for 6 of 6 sampled patients (Patients A, B, C, D, E, and F). See A168 for details.

2. Standard: §482.13(e) (10) also known as A175 - Based on record review and interview, the facility failed to ensure that the patients who had restraints applied were assessed/monitored consistent with facility policy and regulatory requirements for 5 of 6 sampled patients (Patients A, B, C, E, and F). See A175 for details.

3. In an interview with the Director of Quality on 8/18/16 at 10:10 AM, the surveyor was informed that a nurse audits all restraint and seclusion forms to make sure that orders are signed. She stated that the facility has been doing these audits for several months and that when there is an issue the provider is contacted to correct it. The facility had no evidence or documentation of physician contacts that were made as a result of these audits, and there was insufficient evidence to indicate that the facility's Quality audits were effective in addressing the lack of appropriate physician orders for restraint applications. Additionally, there was no evidence to indicate that the facility's quality program had identified the lack of documentation or evidence of patient assessment/monitoring for patients in restraints as an issue that needed to be addressed.